European Journal of Cardiovascular Medicine

Cardiomyopathy is a heterogeneous group of myocardial disorders characterized by structural and functional abnormalities of the heart muscle, often leading to progressive heart failure, arrhythmias, and increased morbidity and mortality.¹ It encompasses various subtypes, including dilated, hypertrophic, restrictive, and arrhythmogenic cardiomyopathies, each with distinct etiologies, clinical manifestations, and prognostic implications. Understanding the clinicodemographic profile of affected patients is crucial for optimizing diagnosis, management, and treatment outcomes.

Dilated cardiomyopathy is the most common type, characterized by enlargement and systolic dysfunction of one or both ventricles, leading to impaired myocardial contractility.² The left ventricle is predominantly affected, resulting in reduced ejection fraction and progressive heart failure. The etiology of DCM can be genetic, idiopathic, or secondary to infections, toxins (such as alcohol or chemotherapy drugs), metabolic disorders, or systemic diseases like autoimmune conditions. Patients with DCM often present with symptoms of congestive heart failure, including dyspnea, fatigue, peripheral edema, and orthopnea. The disease is associated with an increased risk of arrhythmias, thromboembolism, and sudden cardiac death.

Hypertrophic cardiomyopathy is a genetic disorder characterized by abnormal thickening of the myocardium, particularly the interventricular septum, without an identifiable secondary cause such as hypertension or valvular disease.³ This hypertrophy can lead to left ventricular outflow tract obstruction, diastolic dysfunction, and an increased risk of arrhythmias. HCM is a major cause of sudden cardiac death in young athletes. Symptoms include exertional dyspnea, chest pain, palpitations, and syncope. Some patients remain asymptomatic, while others experience progressive heart failure. Diagnosis is typically made using echocardiography, cardiac MRI, and genetic testing. Restrictive cardiomyopathy is the least common type and is characterized by increased myocardial stiffness, leading to impaired ventricular filling during diastole. Unlike DCM and HCM, ventricular size and systolic function are typically preserved.⁴ The disease is often secondary to systemic conditions such as amyloidosis, sarcoidosis, hemochromatosis, or radiation therapy. Patients with RCM frequently develop symptoms of heart failure with preserved ejection fraction (HFpEF), including dyspnea, fatigue, and signs of systemic venous congestion such as ascites and hepatomegaly. Due to its restrictive physiology, RCM is associated with a poor prognosis if left untreated.

Arrhythmogenic right ventricular cardiomyopathy is a hereditary disorder primarily affecting the right ventricle, characterized by progressive fibro-fatty replacement of myocardial tissue.⁵ Ischemic cardiomyopathy (ICM) is a condition characterized by left ventricular dysfunction due to coronary artery disease (CAD) and myocardial ischemia.⁶ It occurs when there is a significant reduction in blood flow to the heart muscle, usually due to atherosclerotic plaque buildup in the coronary arteries, leading to chronic ischemia or previous myocardial infarctions (heart attacks). The repeated episodes of ischemia and infarction result in myocardial scarring, fibrosis, and remodeling, ultimately causing impaired contractility and reduced cardiac output.

Cardiomyopathy is a significant public health concern due to its progressive nature, high morbidity and mortality rates, and its role as a leading cause of heart failure, arrhythmias, and sudden cardiac death. It affects individuals across all age groups, often leading to severe complications that necessitate long-term medical management, hospitalization, and, in advanced cases, heart transplantation.⁷ The increasing prevalence of cardiomyopathy, coupled with its association with genetic predisposition, lifestyle factors, and comorbid conditions, underscores its critical impact on healthcare systems worldwide.

This study aims to investigate the clinico-demographic profile of patients diagnosed with cardiomyopathy, analyzing key factors such as age, gender, socioeconomic background, comorbid conditions, and clinical presentations.

The study was conducted on primary data collected from all the Indoor/Outdoor patients presented at Dr. Susheela Tiwari Memorial Govt. Hospital, GMC Haldwani, Nainital, Uttarakhand for the period of 18 months following IEC Approval. The study included a total of 102 patients presented at Department of General Medicine at Dr. Susheela Tiwari Memorial Govt. Hospital, GMC Haldwani, Nainital, Uttarakhand.

Informed written consent was taken from patients participating in study and ethical clearance was taken from institutional ethical committee GMC Haldwani, Uttarakhand. The data was collected after taking proper history and detailed clinical examination of Indoor/Outdoor patients of Department of General Medicine at Dr. Susheela Tiwari Memorial Govt. Hospital, GMC Haldwani, Nainital, Uttarakhand.

Inclusion & Exclusion Criteria

Inclusion Criteria:

• Patients with symptoms/signs of heart failure.
• Confirmed/ diagnosed cases of cardiomyopathy attending Dr Sushila Tiwari Government Hospital.
• Patients above the age of 16 years.
• Patients who have given informed consent to participate in the study.

Exclusion Criteria:

• Patients who have not given informed consent to participate in the study.
• Patients having Congenital heart díseases or valvular heart disease.
• Patients suffering from Rheumatological disorders.

METHODOLOGY

The study is based on primary data collected through convenient sampling method. 102 patients were selected, irrespective of their age and gender at department of general medicine at GMC Haldwani, during the period of the study. Thereafter, applying statistical techniques, the results were obtained and analysed. All baseline blood investigations were done in the Dept. of Biochemistry and Dept. of Pathology, GMC Haldwani.

DATA MANAGEMENT

All filled questionnaires were coded before entering data into the computer. Data cleaning was done by using consistence checks. Frequency distribution tables were used to summarize the data. Data was presented as number of patients, mean and percentages. The data, thus collected, was analyzed on Microsoft Excel 2007.

ETHICAL CONSIDERATIONS:

Prior to data collection, ethical clearance was sought from the Ethical Committee, Government Medical College, Haldwani, Uttarakhand. Permission to conduct the study was obtained from Government Medical College, Haldwani administration.

Each patient was asked to sign a written consent for the purpose of participating in this study, which included details of all invasive procedures, benefits and potential complications. All information obtained from study participants was kept confidential, and shared only with the attending health care personnel involved. All patients enrolled in the study received all routine services while admitted in the medical ward.

Table 1: Gender distribution

This study's cohort consisted of 102 participants, with a majority being male (64.8%, n=66) compared to female (35.2%, n=36). Regarding educational background, the largest group was illiterate (32.4%, n=33), followed by those with primary school education (19.6%, n=20). A significant portion of participants had at least some secondary education, with high school (16.7%), intermediate (14.7%), and graduate (14.7%) levels being nearly equally represented. Postgraduates formed the smallest group at 2.0% (n=2).

Table 2: Age Distribution of Male and Female Patients

The majority of patients were concentrated in the 61–80 years age group, comprising 28 males and 16 females, indicating that cardiomyopathy predominantly affects the elderly in both sexes.

Table 3: Distribution of patients on the basis of geographical region, social class, Marital Status and religion wise

The data reveals that the majority of the group resides in hilly regions (59.8%), identifies with the middle or lower-middle social classes (collectively 76.5%), is overwhelmingly married (90.2%), and is predominantly Hindu (86.3%). A notable finding is an exact even split in dietary preferences, with half the group being vegetarian and the other half non-vegetarian. Each category is complete and internally consistent, with all subtotals correctly summing to the overall total of 102 individuals, or 100%.

Table 4: NYHA Functional Classification

The distribution of 102 patients by NYHA Class shows that nearly half (45.1%) were in Class II, indicating slight limitation during ordinary activity. Over a quarter (26.5%) were in Class III with marked limitation, while 22.5% were in the most severe, Class IV. A small minority (5.9%) were in the asymptomatic Class I.

Table 5: Distribution of ECG Findings in the Study Population

The most common ECG pattern was sinus rhythm, seen in 58 patients (56.9 percent), indicating a relatively preserved baseline rhythm in more than half of the patients. Atrial fibrillation was the second most common finding, observed in 19 patients (18.6 percent), which is consistent with the known association between cardiomyopathy and atrial arrhythmias. Ventricular premature complexes (VPC) were present in 13 patients (12.7 percent), suggesting underlying ventricular irritability. Sinus bradycardia was noted in 8 patients (7.8 percent), and a single case each of sinus tachycardia and left bundle branch block was identified (1 percent each), pointing to occasional conduction and rate abnormalities.

Table 6: Symptomatology and clinical findings

In the present study involving 102 patients diagnosed with cardiomyopathy, the most commonly reported clinical symptom was paroxysmal nocturnal dyspnea (PND), observed in 87.25% of patients. This finding suggests a high prevalence of left ventricular dysfunction and pulmonary congestion among the study population. Palpitations were reported by 70.59% of patients, indicating a significant incidence of arrhythmias, which are commonly associated with cardiomyopathy. Orthopnea was present in 54.90% of cases, further supporting the evidence of heart failure-related symptoms. The raised jugular venous pressure (JVP) was present in 52.94% of patients, which is a hallmark of right-sided heart failure and indicates elevated central venous pressure. Basal crepitations were noted in 50% of cases, suggesting the presence of pulmonary congestion due to left ventricular dysfunction.

Table 7: Echocardiography findings

The mean end-diastolic diameter (EDD) was 6.06 cm, suggesting enlargement of the left ventricle during diastole, while the mean end-systolic diameter (ESD) was 4.91 cm, indicating persistent dilation even after contraction. These measurements support the presence of left ventricular remodeling and structural changes that occur in response to chronic myocardial stress or injury.

Table 8: LVEF Category Distribution

The analysis of left ventricular ejection fraction (LVEF) in a group of 102 patients shows that all individuals have reduced systolic function, with none reaching the normal value of 55 percent or above. Among them, 43.1 percent fall in the range of 40 to 45 percent, indicating mild left ventricular dysfunction.

In our study, males accounted for 64.8% of the patients, indicating a clear male predominance in the incidence of cardiomyopathy. This is consistent with findings from other studies such as Maron et al. (2006)², which reported that men are more frequently affected by both dilated and ischemic cardiomyopathy. The higher prevalence among males may be attributed to increased exposure to risk factors such as smoking, alcohol use, and higher prevalence of ischemic heart disease among males (Nair et al., 2017).⁸ The majority of our patients belonged to the 61–80 years age group (43.1%), with a notable proportion (40.1%) in the 41–60 years group. These findings are in line with the study by Elliott et al. (2008)¹, which showed that cardiomyopathy, particularly dilated cardiomyopathy, typically presents in middle to older age. The lower representation in the 21–40 age group (13.7%) and >80 age group (2.9%) may reflect the natural history of disease progression and survival bias.

A significant proportion of patients (32.4%) were illiterate, and only 2% had postgraduate education. The association between lower education levels and higher risk of cardiovascular diseases has been well-documented. According to Yusuf et al. (2004)⁹, low educational status correlates with poor health awareness and delayed healthcare-seeking behavior, which may contribute to late presentation and advanced disease at diagnosis. Most of the patients (59.8%) came from hilly regions. This is likely due to the catchment area of the hospital and possibly due to limited access to tertiary care in remote areas. Previous studies by Ghosh et al. (2015)¹⁰ suggest that geographic isolation can impact access to timely healthcare, contributing to more advanced presentations.

A majority of our patients were from the middle (39.2%) and lower middle (37.3%) socioeconomic classes. Low socioeconomic status is a known risk factor for cardiovascular diseases (Kaplan & Keil, 1993).¹¹ It is associated with higher prevalence of modifiable risk factors such as smoking, poor nutrition, and limited access to medical care. Our study found 90.2% of the patients were married. Similar trends were noted by Gupta et al. (2019)¹², indicating that middle-aged and older adults are more commonly affected. Hindu patients formed the majority (86.3%), consistent with the regional demographics. An equal distribution of vegetarians and non-vegetarians was noted in our study. Although diet is a known modifiable risk factor, our findings indicate that dietary pattern alone may not predict cardiomyopathy risk. However, high saturated fat intake in non-vegetarians has been linked to left ventricular dysfunction in other studies (Hooper et al., 2001).¹³ The majority of patients were in NYHA Class 2 (45.1%) and Class 3 (26.5%), reflecting moderate to severe functional limitation. This distribution mirrors the findings by Dec et al. (1992)¹⁴, who reported similar functional impairment in patients with dilated cardiomyopathy. A considerable proportion (22.5%) being in Class 4 indicates late-stage disease, possibly due to delayed diagnosis.

The most prevalent risk factor was smoking (47.1%), followed by diabetes (38.2%) and hypertension (30.4%). These findings align with those of the INTERHEART study (Yusuf et al., 2004)80, which identified these as key modifiable risk factors for cardiovascular disease globally. The presence of alcoholism in 25.5% of patients is also significant, as alcohol is a known cause of dilated cardiomyopathy (McKenna et al., 1997).¹⁵ Paroxysmal Nocturnal Dyspnea (PND) (87.25%) and palpitations (70.59%) were the most common symptoms, indicative of left-sided heart failure and arrhythmias. Similar symptom patterns were reported by Felker et al. (2000)¹⁶, who noted fatigue, dyspnea, and edema as hallmark features of cardiomyopathy. The prevalence of orthopnea (54.9%) and pedal edema (48.04%) further supports the diagnosis of heart failure. Raised JVP (52.94%) and basal crepitations (50%) were frequently observed, consistent with signs of biventricular failure. Added heart sounds and displaced apex beat were present in over 40% of cases, reflecting ventricular remodeling. These signs are consistent with advanced cardiac dysfunction, as described by Jessup & Brozena (2003).³ Sinus rhythm was the most common ECG finding (56.9%), followed by atrial fibrillation (18.6%). Similar distributions were reported by Gotsman et al. (2004)¹⁷, who observed that atrial fibrillation is common in advanced cardiomyopathy. The presence of VPCs (12.7%) and conduction abnormalities also reflects myocardial irritability and structural disease.

In this study of 102 cardiomyopathy patients, the condition was found to predominantly affect elderly males from hilly regions with middle and lower-middle socioeconomic backgrounds. The most common clinical features were paroxysmal nocturnal dyspnea and palpitations, accompanied by raised jugular venous pressure and basal crepitations, highlighting the predominant involvement of both left and right ventricular dysfunction. Echocardiographic findings showed consistently reduced left ventricular ejection fraction and ventricular dilation, correlating with the observed clinical severity. These results highlight the importance of early recognition and comprehensive management of cardiomyopathy, particularly in populations with limited access to healthcare, to improve clinical outcomes.

1. Elliott P, Andersson B, Arbustini E, Bilinska Z, Cecchi F, Charron P, Dubourg O, Kühl U, Maisch B, McKenna WJ, Monserrat L. Classification of the cardiomyopathies: a position statement from the European Society Of Cardiology Working Group on Myocardial and Pericardial Diseases. European heart journal. 2008 Jan 1;29(2):270-6.
2. Maron BJ, Towbin JA, Thiene G, Antzelevitch C, Corrado D, Arnett D, Moss AJ, Seidman CE, Young JB. Contemporary definitions and classification of the cardiomyopathies: an American Heart Association scientific statement from the council on clinical cardiology, heart failure and transplantation committee; quality of care and outcomes research and functional genomics and translational biology interdisciplinary working groups; and council on epidemiology and prevention. Circulation. 2006 Apr 11;113(14):1807-16.
3. Jessup M, Brozena S. Heart failure. N Engl J Med. 2003;348(20):2007-18.
4. Dec GW, Fuster V. Idiopathic dilated cardiomyopathy. N Engl J Med. 1994;331(23):1564-75.
5. Sliwa K, Hilfiker-Kleiner D, Petrie MC, Mebazaa A, Pieske B, Buchmann E, Regitz-Zagrosek V, Schaufelberger M, Tavazzi L, van Veldhuisen DJ, Watkins H. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. European journal of heart failure. 2010 Aug 1;12(8):767-78.
6. Bozkurt B, Colvin M, Cook J, Cooper LT, Deswal A, Fonarow GC, Francis GS, Lenihan D, Lewis EF, McNamara DM, Pahl E. Current diagnostic and treatment strategies for specific dilated cardiomyopathies: a scientific statement from the American Heart Association. Circulation. 2016 Dec 6;134(23):e579-646.
7. Savarese G, Vasko P, Dahlström U, Lund LH. The public health burden of cardiomyopathies: insights from a nationwide inpatient study. Int J Cardiol. 2020;304:133–138.
8. Nair R, Nair SS, Mandal S, Tharakan JM, Jayaprakash K, Haridasan V. Gender differences in clinical presentation and outcomes of cardiomyopathies: a tertiary care experience. Indian Heart Journal. 2017;69(5):542–548.
9. Yusuf S, Hawken S, Ôunpuu S, Dans T, Avezum A, Lanas F, McQueen M, Budaj A, Pais P, Varigos J, Lisheng L. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. The lancet. 2004 Sep 11;364(9438):937-52.
10. Ghosh S, Singh A, Choudhury R, Chatterjee S, Jha S, Dey S. Challenges in providing cardiac care in hilly regions of India: a hospital-based study. Indian Heart Journal. 2015;67(3):202–205.
11. Kaplan GA, Keil JE. Socioeconomic factors and cardiovascular disease: a review of the literature. Circulation. 1993;88(4):1973–1998.
12. Gupta R, Joshi P, Mohan V, Reddy KS, Yusuf S. Epidemiology and causation of coronary heart disease and stroke in India. Heart. 2019;105(6):408–418.
13. Hooper L, Summerbell CD, Thompson R, Sills D, Roberts FG, Moore H, Smith GD. Reduced or modified dietary fat for preventing cardiovascular disease. Cochrane Database Syst Rev. 2001;(3):CD002137.
14. Dec GW, Palacios IF, Fallon JT, Aretz HT, Mills J, Lee DC, Fuster V. Idiopathic dilated cardiomyopathy. N Engl J Med. 1992;326(13):919–928.
15. McKenna WJ, Thiene G, Nava A, et al. Diagnosis of arrhythmogenic right ventricular dysplasia/cardiomyopathy. Br Heart J. 1994;71(3):215-8.
16. Felker GM, Thompson RE, Hare JM, Hruban RH, Clemetson DE, Howard DL, Baughman KL, Kasper EK. Underlying causes and long-term survival in patients with initially unexplained cardiomyopathy. New England Journal of Medicine. 2000 Apr 13;342(15):1077-84.
17. Gotsman I, Keren A, Hellman Y, Zwas DR, Lotan C. Atrial fibrillation in heart failure: prevalence and prognostic significance. Eur J Heart Fail. 2004;6(4):403–409.